Cigna Drug and Biologic Coverage Policy

Transcription

1 Cigna Drug and Biologic Coverage Policy Subject Drugs / Biologics Not Covered Unless Approved Under Medical Necessity Review Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List Table of Contents Coverage Policy... 1 General Background...32 References...33 Effective Date... 4/15/2018 Next Review Date... 1/15/2019 Coverage Policy Number Related Coverage Resources INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations. Coverage Policy Employer group plans may adopt a Prescription Drug List that does not cover certain drugs or biologics unless those products are approved based on a medical necessity review. Cigna approves coverage for these drugs or biologics as medically necessary when sufficient information demonstrates that the clinical criteria set forth below are met. Unless otherwise stated, all Covered Alternative Drugs are required prior to the approval of the non-covered drug or biologic. Note: Receipt of sample product does not satisfy any criteria requirements for coverage Cigna Standard Prescription Drug List or Performance Prescription Drug List Therapeutic Diabetes: Insulins Admelog (insulin lispro) Documented contraindication per FDA label, intolerance, Apidra (insulin glulisine) Afrezza (insulin for inhalation) Lantus (insulin glargine) or inability to use Humalog (insulin lispro) Documented contraindication per FDA label, intolerance, or inability to use Humalog (insulin lispro) Follow Afrezza Coverage Policy #1506 for additional criteria Afrezza Coverage Policy Page 1 of 33

2 Diabetes: Noninsulins (DPP-4 Inhibitors and combination) Toujeo (insulin glargine) Novolog (insulin aspart) Fiasp (insulin aspart) Novolog Mix 70/30 (70% insulin aspart protamine/30% insulin aspart) Novolin 70/30 (70% NPH, human insulin isophane/30% regular human insulin) Novolin N (insulin, NPH human recombinant isophane) Novolin R (insulin, regular, human recombinant) Nesina (alogliptin) Tradjenta (linagliptin) Jentadueto / Jentadueto XR (linagliptin / metformin) Kazano (alogliptin / metformin) Oseni (alogliptin / pioglitazone) Documented contraindication per FDA label, intolerance, or inability to use ALL of the following: Basaglar (insulin glargine), Levemir (insulin detemir), and Tresiba (insulin degludec) Documented contraindication per FDA label, intolerance, or inability to use Humalog (insulin lispro) Documented contraindication per FDA label, intolerance, inability to use or not a candidate for Humalog Mix 75/25 Documented contraindication per FDA label, intolerance, or inability to use Humulin 70/30) Documented contraindication per FDA label, intolerance, or inability to use Humulin N Documented contraindication per FDA label, intolerance, or inability to use Humulin R Nesina Documented contraindication per FDA label or intolerance to BOTH Januvia (sitagliptin), AND Onglyza (saxagliptin) Documented contraindication per FDA label or intolerance to alogliptin, Januvia (sitagliptin), AND Onglyza (saxagliptin) Documented contraindication per FDA label or intolerance to alogliptin / metformin, Janumet (sitagliptin / metformin) / Janumet XR (sitagliptin / metformin), AND Kombiglyze XR (saxagliptin / metformin) Kazano Documented contraindication per FDA label or intolerance to BOTH, Janumet (sitagliptin / metformin) / Janumet XR (sitagliptin / metformin), AND Kombiglyze XR (saxagliptin / metformin) Oseni Documented contraindication per FDA label or intolerance to alogliptin / metformin, Januvia (sitagliptin) /Janumet (sitagliptin / metformin) / Janumet XR (sitagliptin / metformin) AND Onglyza (saxagliptin) / Kombiglyze XR (saxagliptin / metformin) Page 2 of 33

3 Diabetes: Non- Insulin (SGLT2 Inhibitors and combinations) Diabetes: Noninsulins (extended release metformin) Diabetes: Non- Insulin (GLP1) Diabetes: Test Strips Invokana (canagliflozin) Invokamet / Invokamet XR (canagliflozin / metformin) Fortamet (metformin extended release Glumetza (metformin extended release Metformin ER osmotic tablets (Fortamet ) Metformin ER tablets (Glumetza ) Adlyxin (lixisenatide) Tanzeum (albiglutide) Victoza (liraglutide) AccuChek Freestyle Documented intolerance, contraindication per FDA label, or not a candidate for BOTH of the following: Farxiga (dapagliflozin) AND Jardiance (empaglifozin) Documented intolerance, contraindication per FDA label, or not a candidate for BOTH of the following: Synjardy / Synjardy XR (empagliflozin/metformin) AND Xigduo XR (dapagliflozin/metformin) Documented intolerance to metformin ER (Glucophage XR) Documented contraindication per FDA label, intolerance, or inability to use BOTH Trulicity (dulaglutide) AND either Bydureon (exenatide) OR Byetta (exenatide) EITHER of the following: Documented contraindication per FDA label, intolerance, inability to use, or not a candidate for BOTH Trulicity (dulaglutide) AND either Bydureon (exenatide) OR Byetta (exenatide) Diagnosis of both Type 2 diabetes AND cardiovascular disease as defined by the present of ANY of the following: o Coronary heart disease (for example: acute coronary syndromes, history of myocardial infarction, stable or unstable angina, coronary or other arterial revascularization) o Cerebrovascular disease (for example: stroke, transient ischemic attack) o Peripheral vascular disease o Chronic kidney disease o Heart failure (New York Heart Association [NYHA] class II or III) o Age 60 years or more and at least one risk factor for cardiovascular disease (microalbuminuria or proteinuria, hypertension and left ventricular hypertrophy, left ventricular systolic or diastolic dysfunction, or an ankle brachial index of less than 0.9) Page 3 of 33

4 DMARDs- biologic Testosterone Replacement Renal and Genitourinary Agents Contour All other test strips Siliq (brodalumab injection) Axiron Fortesta Natesto Testim Vogelxo Gelnique 10% gel (oxybutynin chloride metered-dose pump, sachet) Myrbetriq (mirabegron) Toviaz (fesoterodine) Vesicare (solifenacin) Detrol / Detrol LA (tolterodine) Ditropan XL (oxybutynin) Duzallo (lesinurad and allopurinol) Documented inability to use BOTH One Touch Ultra AND One Touch Verio due to a physical limitation that makes utilization of the One Touch product not accurate, safe or for other reason not medically appropriate (e.g. manual dexterity, visual impairment, or use of a insulin pump with a dedicated meter) Follow Immunomodulators Coverage Policy #1805 for additional criteria Immunomodulators Coverage Policy Follow Testosterone Therapy Coverage Policy #1503 for additional criteria Testosterone Therapy Coverage Policy candidate for ALL of the following: darifenacin ER, oxybutynin, tolterodine and trospium of Detrol / Detrol LA candidate for ALL of the following: darifenacin ER oxybutynin and trospium Ditropan XL candidate for ALL of the following: darifenacin ER, tolterodine and trospium Diagnosis of symptomatic hyperuricemia associated with gout Failure to achieve target serum uric acid levels with monotherapy on either allopurinol or Uloric* Failure, inadequate response, contraindication per FDA label, documented intolerance, or not a candidate for probenecid in combination with either allopurinol or Uloric* Inability to use Zurampic* and allopurinol separately *may require prior authorization Page 4 of 33

5 Anaphylaxis Therapy Agents Enablex (darifenacin ER) Oxytrol (oxybutynin transdermal system) Adrenaclick (epinephrine 0.15 mg and 0.3 mg auto-injector) Auvi-Q (epinephrine 0.15 mg and 0.3 mg auto-injector) EpiPen (epinephrine 0.3 mg auto-injector) EpiPen Jr (epinephrine 0.15 mg auto-injector) Anti-emetics Marinol (dronabinol 2.5 mg, 5 mg, and 10 mg capsules) Syndros (dronabinol 5 mg/ml oral solution) Zofran (ondansetron 4 mg, 8 mg, 24 mg tablets,4 mg/5 ml solution) Zofran ODT (ondansertron 4 mg, 8 mg orally disintegrating Zuplenz (ondansetron 4 mg and 8 mg film) Enablex candidate for ALL of the following: oxybutynin, tolterodine and trospium Documented inability to use oxybutynin syrup, extended release tablets or tablets Documented intolerance, inability to use, or inability to obtain generic epinephrine auto-injector. Where covered, a maximum of four auto-injectors will be allowed per 30 days. Documented inability to obtain generic epinephrine autoinjector. Where covered, a maximum of four auto-injectors will be allowed per 30 days. Used for the treatment of chemotherapy induced nausea and vomiting or anorexia associated with HIV infection Marinol Documented inability to use oral dronabinol capsules Zofran candidate for Anzemet or granisetron tablets *Certain plans may require prior authorization for Anzemet Documented intolerance or inability to use ondansetron tablets, orally disintegrating tablets, and solution Documented intolerance or inability to use ondansetron tablets, orally disintegrating tablets, and solution Page 5 of 33

6 Anti-diuretic and vasopressor hormone agents Anti-infective agents: antifungals DDAVP (desmopressin acetate 0.01% nasal solution) DDAVP (0.1 mg, 0.2 mg Diflucan (fluconazole 50 mg, 100 mg, 150 mg, 200 mg tablets, 10 mg/ml, 40 mg/ml suspension) Ertaczo (sertaconazole 2 % cream) Extina (ketoconazole 2 % foam) Jublia (efinaconazole 10 % solution) Kerydin (tavaborole 5 % solution) Loprox (ciclopirox 0.77 % cream) Loprox (ciclopirox 1 % shampoo) Luzu DDAVP nasal solution Documented inability to use desmopressin tablets DDAVP Diflucan Individual is 12 years of age and older Documented diagnosis of interdigital tinea pedis Documented inadequate response, contraindication per FDA label, or intolerance to naftifine cream, clotrimazole cream, and econazole cream Extina 2 % foam Individual is 12 years of age and older Documented diagnosis of seborrheic dermatitis candidate for sulfacetamide sodium shampoo and ciclopirox shampoo Individual is an adult (18 years of age and older) Documented diagnosis of onychomycosis of the toenail(s) Documented inadequate response, contraindication per FDA label, intolerance, or not a candidate for itraconazole capsules, terbinafine tablets, and ciclopirox nail lacquer solution Loprox 0.77 % cream candidate for FOUR of the following: naftifine cream, clotrimazole cream, econazole cream, oxiconazole cream, or ketoconazole cream Loprox 1 % shampoo Individual is an adult (18 years of age and older) Documented diagnosis of seborrheic dermatitis candidate for sulfacetamide sodium shampoo and ketoconazole foam Individual is an adult (18 years of age and older) Page 6 of 33

7 Anti-infective agents: antiprotozoals (luliconazole 1 % cream) Onmel (itraconazole 200 mg tablets, 10 mg/ml solution) Sporanox (itraconazole 100mg capsules, 10 mg/ml solution) Oxistat (oxiconazole 1% lotion) Oxistat (oxiconazole 1 % cream) Penlac (ciclopirox 8 % nail lacquer solution) Vusion (miconazole / zinc oxide 0.25 % - 15 % ointment) Mepron (atovaquone 750 mg/ 5 ml oral suspension) Documented diagnosis of tinea pedia, tinea cruris, or tinea corporis Documented inadequate response, contraindication per FDA label, or intolerance to naftifine cream, clotrimazole cream, and econazole cream Documented intolerance or inability to use itraconazole 100 mg capsules candidate for terbinafine tablets Sporanox Documented failure / inadequate response to oxiconazole 1 % cream candidate for ketoconazole cream Oxistat 1 % cream candidate for ketoconazole cream Penlac 8 % nail lacquer solution Documented diagnosis of onychomycosis of the fingernail(s) or toenail(s) Documented inadequate response, contraindication per FDA label, intolerance, or not a candidate for itraconazole capsules and terbinafine tablets Pediatric individual 4 weeks of age or older Documented diagnosis of diaper dermatitis Presence of candida infection The approval will be limited to a seven day supply. One of the following: Prevention or treatment of Pneumocystis jiroveci pneumonia (PCP) in adults or individuals 13 years of age and older o Documented intolerance to 1 generic formulation of Mepron AND o Documented intolerance to trimethoprim/sulfamethoxazole (TMP-SMX) Prevention or treatment of Toxoplasma gondii encephalitis (TE) in adults or adolescents o Documented intolerance to 1 generic formulation of Mepron AND Page 7 of 33

8 Anti-infective agents: inhaled aminoglycosides Anti-infective agents: antivirals Anti-infective agents: Penicillins Bethkis (tobramycin 300 mg / 4 ml nebulization solution) Tobi (tobramycin 300 mg / 5 ml nebulization solultion) Sitavig (acyclovir 50 mg buccal tablet) Zovirax (acyclovir 5% cream) Zovirax (acyclovir 5% ointment) Zovirax (acyclovir 200 mg capsules, 400 mg and 800 mg tablets, 200 mg/5 ml suspension) Xerese (acyclovir / hydrocortisone 5 % - 1 % cream) Valcyte (valganciclovir 450 mg tablets, 50 mg/ml solution) Augmentin (125 mg amoxicillin /31.25mg clavulanate/5ml suspension, 250 mg amoxicillin / 62.5mg clavulanate/5ml suspension, 875 mg amoxicillin/125 mg clavulanate o Documented intolerance to 1 of the following: trimethoprim/sulfamethoxasole (TMP-SMX), pyrimethamine or sulfadiazine Documented intolerance to tobramycin 300 mg / 5 ml nebulization solution Documented intolerance or inability to use Tobi Podhaler Documented intolerance to Kitabis Pak (tobramycin 300 mg / 5 ml nebulization solution) Tobi nebulization solution Documented intolerance or inability to use Tobi Podhaler Documented intolerance to Kitabis Pak (tobramycin 300 mg / 5 ml nebulization solution) Documented diagnosis of recurrent herpes labialis Documented inability to use acyclovir capsules and tablets Zovirax ointment Documented inability to use acyclovir capsules and tablets Documented contraindication per FDA label, intolerance, inability to use, or not a candidate for valacyclovir tablets and famciclovir tablets Zovirax Documented inability to use acyclovir tablets and hydrocortisone cream concurrently Valcyte Augmentin Page 8 of 33

9 Augmentin ES- 600 (600 mg amoxicillin /42.9 mg clavulanate / 5 ml suspension) Anti-infective agents: Macrolides Anti-infective agents: topical antibiotics Anti-infective agents: Vancomycin and Derivaties Anti-inflammatory combination products Augmentin XR (1,000 mg amoxicillin /62.5 mg clavulanate E.E.S. 200 (erythromycin ethylsuccinate 200 mg/5 ml suspension) EryPed 400 (erythromycin 400 mg/5 ml suspension) Plexion (sulfacetamide sodium / sulfur 9.8 % 4.8 % cleanser, cleansing cloth, cream, and lotion) Vancocin (Vancomycin 125 mg, 250 mg capsules Duexis (famotidine / ibuprofen 26.6 mg 800 mg Vimovo (esomeprazole / naproxen 20 mg 375 mg or 500 mg Antineoplastics Nilandron (nilutamide 150 mg Anti- Parkinson Agents Gocovri (amantadine) extended release capsules E.E.S. 200 Documented inability to use or not a candidate for erythromycin ethylsuccinate 400 mg tablets Documented failure / inadequate response or intolerance to five of the following: o sulfacetamide sodium / sulfur 10 % - 5 % emollient cream, topical lotion, and topical cleanser o sulfacetamide sodium / sulfur 10 % - 4 % cleansing pads o sulfacetamide sodium / sulfur 9 % % topical wash Vancocin Documented inability to use famotidine 20 mg or 40 mg tablets and ibuprofen 800 mg tablets concurrently Documented inability to use esomeprazole 20 mg capsules and naproxen 375 mg or 500 mg tablets concurrently Follow Oncology Medications Coverage Policy #1403 for additional criteria Oncology Medications Cover Policy ALL of the following: For the treatment of dyskinesia in patients with Parkinson's disease (PD) Receiving levodopa-based treatment Documented failure/inadequate response or intolerance to amantadine immediate-release capsules, tablets, or oral solution Page 9 of 33

10 Lodosyn (carbidopa 25 mg Requip XL (ropinerole 2 mg, 4 mg, 6 mg, 8 mg, 12 mg extended release Zelapar (seligiline 1.25 mg orally disintegrating Antitussive Agents Tussicaps (chlorpheniramine / hydrocodone 4 mg 5 mg and 8 mg 10 mg extended release capsules) Dermatologic: Acne Agents, Topical Benzaclin (benzoyl peroxide / clindamycin 5 % - 1% topical gel) Duac (benzoyl peroxide / clindamycin 5 % % topical gel) Clindagel (clindamycin 1 % gel) Ziana (clindamycin / tretinoin 1.2 % %) Lodosyn Individual is currently on a carbidopa/levodopa regimen Requip XL candidate for (e.g., stabilized condition where therapeutic interchange is inappropriate) for the following: pramipexole extended release tablets candidate for (e.g., stabilized condition where therapeutic interchange is inappropriate) ONE of the following:rasagiline or seligiline tablets Documented inability to use chlorpheniramine / hydrocodone 8 mg 10 mg / 5 ml extended release suspension Benzaclin candidate for ALL of the following: o benzoyl peroxide / clindamycin 5 % % topical gel o benzoyl peroxide / erythromycin 5 % - 3 % topical gel Duac Documented intolerance to Neuac candidate for ALL of the following: o benzoyl peroxide / clindamycin 5 % - 1 % topical gel o benzoyl peroxide / erythromycin 5 % - 3 % topical gel Documented failure / inadequate response or intolerance to clindamycin 1 % solution, lotion, gel, foam, and swab candidate for Aczone Ziana Documented intolerance to Veltin (clindamycin /tretinoin 1.2% % gel) Documented failure / inadequate response or inability to use topical clindamycin with topical tretinoin concurrently Page 10 of 33

11 Dermatologic: Local anesthetics, topical Dermatologic: Steroidal Antiinflammatory, Topical Lidocaine 3% lotion Lido-K (lidocaine 3% lotion) Anusol-HC (hydrocortisone 2.5 % rectal cream) Anusol-HC (hydrocortisone acetate 25 mg rectal suppository) Cortifoam (hydrocortisone acetate 10 % foam) Proctocort (hydrocortisone 1 % cream) Proctocort (hydrocortisone 30 mg suppository) Clobex (clobetasol 0.05 % lotion, liquid spray, shampoo) Cutivate (fluticasone 0.05% cream, lotion) Halog (halcinonide 0.1% cream) Halog (halcinonide 0.1% ointment) Locoid (hydrocortisone butyrate 0.1 % cream, lipocream, lotion, ointment, solution) Documented failure / inadequate response or intolerance to both lidocaine 3 % cream and lidocaine 5 % ointment intolerance, or not a candidate for ALL of the following o hydrocortisone 1 % or 2.5 % rectal cream o o hydrocortisone 100 mg / 60 ml rectal enema hydrocortisone acetate 25 mg or 30 mg rectal suppository Documented failure / inadequate response or intolerance to FIVE dosage forms of clobetasol 0.05 %: lotion, liquid spray, shampoo, solution, ointment, cream, gel, or foam Cutivate contraindication per FDA label, or intolerance to betamethasone, clocortolone, desoximetasone, fluocinonide, flurandrenolide, hydrocortisone, mometasone, prednicarbate, triamcinolone contraindication per FDA label, or intolerance to triamcinolone cream, fluocinonide cream, betamethasone cream, halobetasol cream, and clobetasol cream contraindication per FDA label, or intolerance to triamcinolone ointment, fluocinonide ointment, betamethasone ointment, halobetasol ointment, and clobetasol ointment Documented failure / inadequate response or intolerance to hydrocortisone butyrate 0.1 % solution, ointment, cream, and lipid cream Page 11 of 33

12 Dermatologic: Acne Agents, Systemic Dermatologic: Antineoplastics, Topical Kenalog (triamcinolone acetonide mg / gm aerosol solution) Trianex (augmented triamcinolone acetonide 0.05 % ointment) Ultravate (halobetasol propionate 0.05 % lotion) Ultravate X (halobetasol propionate / lactic acid 0.05 % - 10 % cream) Ultravate X (halobetasol propionate / lactic acid 0.05 % - 10 % ointment) Verdeso (desonide 0.05 % foam) Vanos (fluocinonide 0.1 % cream) Sernivo (betamethasone dipropionate 0.05 % emulsion) Absorica (isotretinoin 10 mg, 20 mg, 25 mg, 30 mg, 35 mg, and 40 mg capsules) Aldara (imiquimod 5 % cream) Kenalog Documented failure / inadequate response or intolerance to ALL of the following: Triamcinolone acetonide cream, lotion and ointment Documented failure / inadequate response or intolerance to ALL of the following: Triamcinolone acetonide cream, lotion and ointment Documented failure / inadequate response or intolerance to FIVE of the following: o halobetasol propionate 0.05 % cream o halobetasol propionate 0.05 % ointment o clobetasol propionate 0.05 % cream o clobetasol propionate 0.05 % lotion o clobetasol propionate 0.05 % ointment o betamethasone dipropionate, augmented 0.05 % ointment o betamethasone dipropionate, augmented 0.05 % lotion contraindication per FDA label, or intolerance to fluocinolone body oil, fluticasone lotion, and topical hydrocortisone Vanos 0.1 % cream Documented failure / inadequate response or intolerance to fluocinonide 0.05 % solution, ointment, cream, and gel intolerance, or not a candidate for FIVE of the following: o betamethasone dipropionate 0.05 % ointment o betamethasone dipropionate 0.05 % cream o betamethasone dipropionate 0.05 % lotion o augmented betamethasone dipropionate 0.05 % gel o betamethasone valerate 0.12 % foam Documented intolerance to Claravis (isotretinoin 10 mg, 20 mg, 30 mg, and 40 mg capsules), Myorisan (isotretinoin 10 mg, 20 mg, and 40 mg capsules), and Zenatane (isotretinoin 10 mg, 20 mg, 30 mg, and 40 mg capsules) Aldara One of the following: Page 12 of 33

13 Zyclara (imiquimod 2.5 % cream pump) Zyclara (imiquimod 3.75 % cream pump, and 3.75 % cream) Carac (fluorouracil 0.5 % cream) o For actinic keratosis: Documented failure or inadequate response, contraindication per FDA label, intolerance or not a candidate for ALL of the following topical therapies: 5-fluorouracil cream (flurouracil 0.5% cream, Fluoroplex 1%, Tolak 4%, Efudex 5%) 5-fluorouracil solution (2% or 5%) Picato (ingenol) 0.015% or 0.05% gel o For superficial basal cell carcinoma: Documented failure or inadequate response, contraindication per FDA label, intolerance or not a candidate for topical 5- fluorouracil 5% (cream or solution) o For external genital and perianal warts (Condylomata acuminata): Documented failure or inadequate response, contraindication per FDA label, intolerance or not a candidate for ALL of the following topical therapies: podofilox 0.5% (solution, Condylox gel) Veregen (sinecatechins) 15% ointment Documented failure or inadequate response, contraindication per FDA label, intolerance or not a candidate for ALL of the following topical therapies: o 5-fluorouracil cream (flurouracil 0.5% cream, Fluoroplex 1%, Tolak 4%, Efudex 5%) o 5-fluorouracil solution (2% or 5%) o imiquimod 5% cream o Picato (ingenol) 0.015% or 0.05% gel One of the following: For actinic keratosis: Documented failure or inadequate response, contraindication per FDA label, intolerance or not a candidate for ALL of the following topical therapies: o 5-fluorouracil cream (flurouracil 0.5% cream, Fluoroplex 1%, Tolak 4%, Efudex 5%) o 5-fluorouracil solution (2% or 5%) o imiquimod 5% cream o Picato (ingenol) 0.015% or 0.05% gel For external genital and perianal warts (Condylomata acuminata): Documented failure or inadequate response, contraindication per FDA label, intolerance or not a candidate for ALL of the following topical therapies: o imiquimod 5% cream o podofilox 0.5% (solution, Condylox gel) o Veregen (sinecatechins) 15% ointment Carac Documented failure or inadequate response, contraindication per FDA label, intolerance or not a candidate for ALL of the following topical therapies: o 5-fluorouracil cream (Fluoroplex 1%, Tolak 4%, Efudex 5%) o 5-fluorouracil solution (2% or 5%) o imiquimod 5% cream o Picato (ingenol) 0.015% or 0.05% gel Page 13 of 33

14 Dermatologic: Antipruritics, Topical Dermatologic: Antipsoriatic agents, systemic Dermatologic: Keratolytics Dermatologic: Topical rosacea agents Analgesics: Non-salicylate and Barbiturate Prudoxin (doxepin 5 % cream) Zonalon (doxepin 5 % cream) Soriatane (acitretin 10 mg, 17.5 mg, 22.5 mg, 25 mg capsules) Bensal HP (salicyclic acid 3 % ointment) Salex 6% cream kit (salicyclic acid 6 % cream) Salex 6% lotion kit (salicyclic acid 6 % lotion) Salex 6% shampoo (salicyclic acid 6 % shampoo) Noritate (metronidazole 1 % cream) Bupap (acetaminophen / butalbital 300 mg 50 mg Vanatol LQ (butalbital 50 mg, acetaminophen 325 Zonalon candidate for three generic prescription topical corticosteroid formulations candidate for topical tacrolimus One of the following: Documented diagnosis of severe psoriasis o Documented intolerance to 1 generic formulation of Soriatane o Documented failure / inadequate response, contraindication per FDA label, intolerance, or not a candidate for ONE of the following: methotrexate or cyclosporine Documented diagnosis of discoid lupus erythematosus o Documented intolerance to 1 formulation of Soriatane o Documented failure / inadequate response, contraindication per FDA label, intolerance, or not a candidate for hydroxychloroquine Documented inability to use or not a candidate for salicylic acid 6 % cream, salicylic acid 6 % lotion, salicylic acid 6 % gel, and salicylic acid 6 % shampoo Documented failure / inadequate response or inability to use metronidazole 0.75 % cream, metronidazole 0.75 % lotion, metronidazole 0.75 % gel, and metronidazole 1 % gel Documented intolerance or not a candidate for acetaminophen / butalbital 325 mg 50 mg tablets Documented contraindication per FDA label, intolerance, or inability to use acetaminophen / butalbital / caffeine 325 mg 50 mg 40 mg capsules AND tablets Page 14 of 33

15 Analgesics: Antimigraine preparations mg, caffeine 40 mg/ 15 ml syrup) Vanatol S (butalbital 50 mg, acetaminophen 325 mg, caffeine 40 mg/ 15 ml syrup) D.H.E 45 (dihydroergotamine mesylate 1 mg/ml Injection) Imitrex (sumatriptan 6 mg/ 0.5 ml refill) Imitrex (sumatriptan 25 mg, 50mg, and 100 mg Imitrex (sumatriptan 5 mg/spray and 20 mg/spray nasal spray) Migranal (dihydroergotamine mesylate nasal solution) Documented contraindication per FDA label, intolerance, or inability to use acetaminophen / butalbital / caffeine 325 mg 50 mg 40 mg capsules AND tablets D.H.E 45 Documented intolerance, not a candidate for, or inability to use sumatriptan injection Documented intolerance, not a candidate for, or inability to use ALL of the following: o oral sumatriptan tablets o sumatriptan nasal spray o sumatriptan succinate solution for injection Imitrex tablets Documented failure/inadequate response, contraindication per FDA label, intolerance, or not a candidate for ONE of the following: oral rizatriptan tablets, oral almotriptan tablets, oral eletriptan tablets, oral frovatriptan tablets, sumatriptan succinate solution for injection, oral zolmitriptan tablets Imitrex nasal spray Documented intolerance, inability to use, or not a candidate for Onzetra Xsail (sumatriptan nasal powder) Documented failure/inadequate response, contraindication per FDA label, intolerance, or not a candidate for ONE of the following: oral rizatriptan tablets, oral almotriptan tablets, oral eletriptan tablets, oral frovatriptan tablets, oral sumatriptan tablets, sumatriptan succinate solution for injection Migranal Documented failure/inadequate response, contraindication per FDA label, intolerance, or not a candidate for sumatriptan nasal spray Documented failure/inadequate response, contraindication per FDA label, intolerance, or not a candidate for ONE of the following: oral rizatriptan tablets, oral almotriptan tablets, eletriptan oral tablets, oral frovatriptan tablets, oral sumatriptan tablets, sumatriptan succinate solution for injection Page 15 of 33

16 Treximet (naproxen sodium / sumatriptan succinate 60 mg 10 mg tablets and 500 mg 85 mg Sumavel DosePro (sumatriptan succinate 4 mg or 6 mg / 0.5 ml jet injector) Zembrace SymTouch (sumatriptan succinate 3 mg / 0.5 ml auto-injector) Zomig (zolmitriptan 2.5 mg and 5 mg Zomig (zolmitriptan 2.5 mg/spray and 5 mg/spray nasal spray) Zomig-ZMT (zolmitriptan 2.5 mg and 5 mg orally disintegrating Documented intolerance to generic Treximet Documented inability to use naproxen and sumatriptan concurrently. Note: Naproxen is available generically as a prescription product in the following strengths and dosage forms: 250 mg, 375 mg, and 500 mg tablets and 125 mg / 5 ml oral suspension. Sumatriptan is available generically in the following strengths: 25 mg, 50 mg, and 100 mg tablets. Documented intolerance, not a candidate for, or inability to use ALL of the following: o oral sumatriptan tablets o o sumatriptan nasal spray sumatriptan succinate 4 mg or 6 mg / 0.5 ml solution for injection Zomig tablets Documented failure/inadequate response, contraindication per FDA label, intolerance, or not a candidate for ONE of the following: oral rizatriptan tablets, oral almotriptan tablets, oral eletriptan tablets, oral frovatriptan tablets, oral sumatriptan tablets, sumatriptan succinate solution for injection One of the following: Treatment of migraine headaches and ALL of the following o Documented intolerance to 1 generic formulation of Zomig tablets o Documented failure/inadequate response, candidate for sumatriptan nasal spray o Documented failure/inadequate response, candidate for ONE of the following: oral rizatriptan tablets, oral almotriptan tablets, oral eletriptan tablets, oral frovatriptan tablets, oral sumatriptan tablets, sumatriptan succinate solution for injection Treatment of cluster headaches AND documented intolerance, not a candidate for, or inability to use sumatriptan injection Zomig- ZMT Documented failure/inadequate response, contraindication per FDA label, intolerance, or not a candidate for ONE of the following: rizatriptan orally disintegrating tablets,oral rizatriptan tablets, oral almotriptan tablets, oral eletriptan Page 16 of 33

17 Analgesics: Narcotics Analgesics: Non-salicylate and Narcotic combinations Analgesics: Nonsteroidal Antiinflammatory Drugs Belbuca (buprenorphine buccal film) Conzip (tramadol 100 mg, 200 mg, and 300 mg extended release capsules) levorphanol (levorphanol 2 mg OxyContin (oxycodone hydrochloride 10 mg,15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg extended-release Roxicodone (oxycodone hydrochloride 5 mg, 15 mg, 30 mg immediate release Capital with codeine (acetaminophen / codeine phosphate 120 mg - 12 mg / 5 ml suspension) Cambia (diclofenac 50 mg powder packet) Naprelan (naproxen 375 mg, 500 mg, and 750 mg extended release naproxen CR tablets, oral frovatriptan tablets, oral sumatriptan tablets, sumatriptan succinate solution for injection Documented intolerance, not a candidate for, or inability to use buprenorphine transdermal patch (Butrans ) Conzip Documented intolerance or inability to use BOTH of the following: tramadol 50 mg tablets (Ultram ) AND tramadol 100 mg, 200 mg, or 300 mg extended release tablets (Ryzolt ) Follow Opioid Therapy Coverage Policy #1704 for additional criteria Opioid Therapy Coverage Policy Documented intolerance to acetaminophen / codeine phosphate 120 mg - 12 mg / 5 ml solution Documented intolerance, not a candidate for, or inability to use acetaminophen / codeine tablets Adult individual 18 years of age or older Used for the acute treatment of migraine attacks Documented intolerance or inability to use diclofenac tablets or diclofenac delayed release tablets Documented contraindication per FDA label, intolerance, inability to use, or not a candidate for FOUR generic nonsteroidal anti-inflammatory drugs (excluding diclofenac) contraindication per FDA label, intolerance, inability to use, or not a candidate for generic triptans Documented intolerance to naproxen 250 mg, 375 mg, or 500 mg immediate release tablets Documented contraindication per FDA label, intolerance, or not a candidate for four generic nonsteroidal antiinflammatory drugs (excluding naproxen) Page 17 of 33

18 Anti-infective agents: Tetracycline Antibiotics (naproxen 375 mg and 500 mg controlled release naproxen ER (naproxen 375 mg and 500 mg extended release Sprix (ketorolac nasal solution; mg / spray) Tivorbex (indomethacin 20 mg and 40 mg capsules) Vivlodex (meloxicam 5 mg and 10 mg capsules) Zipsor (diclofenac 25 mg capsule) Zorvolex (diclofenac 18 mg and 35 mg capsule) Adoxa (doxycycline monohydrate 50 mg and 100 mg tablets, 150 mg capsules, and Pak) Doryx (doxycycline hyclate 50 mg, 120 mg, 150 mg, and 200 mg delayed release Documented contraindication per FDA label, intolerance, or inability to use ketorolac 10 mg tablets contraindication per FDA label, inability to use, or not a candidate for diclofenac 1 % topical gel (Voltaren gel) Documented contraindication per FDA label, inability to use, or not a candidate for THREE generic nonsteroidal anti-inflammatory drugs (excluding ketorolac) The approval will be limited to a five day supply. Documented intolerance to indomethacin 25 mg or 50 mg capsules Documented contraindication per FDA label, inability to use, or not a candidate for FOUR generic nonsteroidal antiinflammatory drugs (excluding indomethacin) Documented intolerance to meloxicam 7.5 mg or 15 mg tablets Documented contraindication per FDA label, inability to use, or not a candidate for FOUR generic nonsteroidal antiinflammatory drugs (excluding meloxicam) Documented intolerance to diclofenac 50 mg tablets or diclofenac 25 mg delayed release tablets Documented contraindication per FDA label, inability to use, or not a candidate for FOUR generic nonsteroidal antiinflammatory drugs (excluding diclofenac) Adoxa, where available Documented intolerance to doxycycline monohydrate 50 mg, 75 mg, 100 mg, or 150 mg capsules intolerance, or not a candidate for the following: o doxycycline hyclate extended release 50 mg, 75 mg, 100 mg, 150 mg, or 200 mg tablets Doryx, where available intolerance, or not a candidate for ALL of the following: Page 18 of 33

19 Minocin (minocycline 50 mg, 75 mg, and 100 mg capsules) Monodox (doxycycline monohydrate 50 mg, 75 mg, and 100 mg capsules) Targadox (doxycycline hyclate 50 mg Vibramycin (doxycycline hyclate 100 mg capsules) Solodyn (minocycline 55 mg, 65 mg, 80 mg, 105 mg, and 115 mg extended release Ximino ER (minocycline 45 mg, 90 mg, 135 mg extended release capsules) o minocycline 45 mg, 90 mg, or 135 mg extended release tablets o doxycycline hyclate 50 mg or 100 mg capsules o doxycycline monohydrate 50 mg, 75 mg, 100 mg, or 150 mg capsules Minocin, where available intolerance, or not a candidate for ALL of the following: o minocycline 50 mg, 75 mg, or 100 mg tablets o minocycline 45 mg, 90 mg, or 135 mg extended release tablets Monodox intolerance, or not a candidate for ALL of the following: o doxycycline monohydrate 50 mg, 75 mg, or 100 mg tablets o doxycycline hyclate 50 mg, 75 mg, or 100 mg delayed release tablets o minocycline 50 mg, 75 mg, or 100 mg capsules Documented failure / inadequate response or intolerance to doxycycline hyclate 50 mg capsules intolerance, or not a candidate for ALL of the following: o doxycycline hyclate extended release 50 mg, 75 mg, 100 mg, 150 mg, or 200 mg tablets o doxycycline hyclate 50 mg or 100 mg capsules o doxycycline monohydrate 75 mg or 150 mg capsules Vibramycin intolerance, or not a candidate for ALL of the following: o doxycycline hyclate 100 mg tablets o doxycycline hyclate 100 mg delayed release tablets o doxycycline monohydrate 100 mg capsules Documented intolerance or inability to use multiple tablets of minocycline 45 mg, 90 mg, or 135 mg extended release tablets intolerance, or not a candidate for ALL of the following: o doxycycline hyclate extended release 50 mg, 75 mg, 100 mg, or 150 mg tablets o minocycline 50 mg, 75 mg, or 100 mg tablets o minocycline 50 mg, 75 mg, or 100 mg capsules Page 19 of 33

20 Cardiovascular: Antithrombotic Agents Cardiovascular: Beta-blockers Cardiovascular: Diuretics Cardiovascular: Inotropic Agents Acticlate (doxycycline hyclate 75 mg and 150 mg Oracea (for rosacea only) (doxycycline monohydrate 40 mg biphasic release capsules) Yosprala (aspirin delayed release / omeprazole 81 mg 40 mg tablets and mg Betapace (sotalol 80 mg, 120 mg, 160 mg Edecrin (ethacrynic acid 25 mg ethacrynic acid (ethacrynic acid 25 mg Lanoxin (digoxin 125 mcg and 250 mcg Lanoxin (digoxin 62.5 mcg and mcg Cardizem Documented failure / inadequate response or intolerance to doxycycline hyclate 75 mg, 100 mg or 150 mg tablets intolerance, or not a candidate for ALL of the following: o doxycycline hyclate extended release 50 mg, 75 mg, 100 mg, 150 mg, or 200 mg tablets o doxycycline hyclate 50 mg or 100 mg capsules o doxycycline monohydrate 75 mg or 150 mg capsules Oracea intolerance, or not a candidate for ALL of the following: o doxycycline monohydrate 50 mg tablets o doxycycline hyclate 50 mg delayed release tablets o minocycline 45 mg extended release tablets Individual is at risk of developing aspirin associated gastric ulcers defined as EITHER of the following o 55 years of age or older o Documented history of gastric ulcers Individual requires aspirin for secondary prevention of cardiovascular and cerebrovascular events defined as ONE of the following: o Previous ischemic stroke or transient ischemia of the brain due to fibrin platelet emboli o Previous myocardial infarction or unstable angina pectoris o Chronic stable angina pectoris o History of revascularization procedure (coronary artery bypass graft or percutaneous transluminal coronary angioplasty) when there is pre-existing condition for which aspirin is already indicated Documented intolerance to immediate release (including enteric coated) aspirin Betapace candidate for ALL of the following: bumetanide, furosemide, and torsemide Lanoxin 125 mcg or 250 mcg tablets Documented inability to use or intolerance to one-half or one and one-half tablets of digoxin 125 mcg tablets Page 20 of 33

21 Cardiovascular: Vasodilators Cholesterol Lowering Gastrointestinal Agents: Aminosalicylates (diltiazem 30 mg, 60 mg, and 120 mg Cardizem CD (diltiazem 120 mg, 180 mg, 240 mg, 300 mg, and 360 mg extended release capsules) GoNitro (nitroglycerin sublingual powder) Isordil (isosorbide dinitrate 40 mg tablet) Isordil Titradose (isosorbide dinitrate 5 mg tablet) Antara (fenofibrate 30 mg and 90 mg capsules) Fenoglide (fenofibrate 40 mg and 120 mg FloLipid (simvastatin) Lipitor (atorvastatin) Asacol HD (mesalamine) Colazal (balsalazide) Cardizem candidate for ALL of the following o Verapamil 40 mg, 80 mg, and 120 mg tablets o Diltiazem CD extended release capsules o Diltiazem extended release tablets Cardizem CD candidate for ALL of the following o Verapamil extended release tablets o Verapamil extended release capsules o Diltiazem extended release tablets Documented intolerance or inability to use nitroglycerin sublingual tablets and nitroglycerin sublingual spray Documented inability to use two tablets of isosorbide dinitrate 20 mg tablets Isordil Titradose 5 mg tablets Documented intolerance to fenofibrate 43 mg, 67 mg, or 130 mg capsules intolerance, or not a candidate for fenofibric acid (Trilipix ), fenofibrate (Tricor / Lofibra ), and gemfibrozil (Lopid ) Documented intolerance to fenofibrate 48 mg or 120 mg tablets intolerance, or not a candidate for fenofibric acid (Trilipix ), fenofibrate (Tricor / Lofibra ), and gemfibrozil (Lopid ) Documented inability to use simvastatin tablet Documented failure/inadequate response, contraindication per FDA label, intolerance, inability to use, or not a candidate for ALL of the following: atorvastatin, lovastatin, rosuvastatin and pravastatin Lipitor Documented intolerance to rosuvastatin, simvastatin, and pravastatin candidate for Apriso (mesalamine), Lialda (mesalamine), Pentasa (mesalamine), balsalazide, and sulfasalazine Page 21 of 33

22 Gastrointestinal Agents: Glucocorticoids Gastrointestinal Agents: Anticholinergic combinations Gastrointestinal Agents: Antiinfective combinations Delzicol (mesalamine) Dipentum (olsalazine) Giazo (balsalazide) mesalamine (Asacol HD authorized generic) Rowasa (mesalamine 4 gm/ 60 ml rectal suspension) Uceris (budesonide 9 mg extended release tablet) Uceris (budesonide 2 mg / act rectal foam) Librax (chlordiazepoxide / clidinium bromide 5 mg 2.5 mg capsules) Omeclamox -Pak (amoxicillin / clarithromycin / omeprazole 500 mg 500 mg 20 mg) Prevpac (amoxicillin / clarithromycin / lansoprazole 500 mg 500 mg 30 mg) Pylera (bismuth subcitrate / metronidazole / tetracycline 140 mg 125 mg 125 mg capsules) Documented intolerance ot 1 generic formulation fo Rowasa intolerance or inability to use Canasa contraindication per FDA label, or intolerance to ALL of the following: hydrocortisone, methylprednisolone, prednisone, and prednisolone contraindication per FDA label, or intolerance to BOTH of the following: hydrocortisone 100 mg / 60 ml rectal enema, and hydrocortisone 25 mg or 30 mg rectal suppository Librax contraindication per FDA label, or intolerance to dicyclomine capsules Documented diagnosis of Helicobacter pylori infection Documented contraindication per FDA label, intolerance, or not a candidate for 1 generic formulation of Prevpac Documented inability to obtain amoxicillin 500 mg tablets or capsules, clarithromycin 500 mg tablets, and omeprazole 20 mg tablets or capsules Documented diagnosis of Helicobacter pylori infection Prevpac Documented inability to obtain amoxicillin 500 mg tablets or capsules, clarithromycin 500 mg tablets, and lansoprazole 30 mg capsules Documented diagnosis of Helicobacter pylori infection Documented failure, contraindication per FDA label, intolerance, or not a candidate for 1 generic formulation of Prevpac Page 22 of 33

23 Gastrointestinal Agents: Chronic Idiopathic Constipation Gastrointestinal Agents: Histamine H2 Antagonists Gastrointestinal Agents: Motility Stimulant Gastrointestinal Agents: Proton Pump Inhibitors Trulance (plecanatide) Pepcid (famotidine 20 mg, 40 mg tablets, and 40 mg / 5 ml suspension) Metozolv ODT (metoclopramide 5 mg orally disintegrating Nexium (esomeprazole) Prevacid Solutab (lansoprazole delayed release orally disintegrating Omeprazolesodium bicarbonate (omeprazole / sodium bicarbonate capsules, packets) Zegerid (omeprazole / sodium bicarbonate capsules, packets) Documented inability to use or obtain bismuth subsalicylate tablets or suspension, metronidazole tablets, and tetracycline capsules concurrently Either of the following: Documented diagnosis of chronic idiopathic constipation (CIC) AND both of the following: o Individual is 18 years and older o Documented failure/inadequate response, contraindication per FDA label, or intolerance to Amitiza and Linzess Documented diagnosis of irritable bowel syndrome with constipation AND both of the following: o o Individual is 18 years and older Documented failure/inadequate response, candidate for Amitiza and Linzess Pepcid candidate for TWO of the following: cimetidine (tablet or solution), nizatidine (capsule or solution), or ranitidine (tablet, capsule, or syrup) Metozolv ODT Documented inability to use metoclopramide tablets and solution Nexium candidate for FOUR of the following: rabeprazole, lansoprazole, omeprazole, pantoprazole, or Dexilant Documented inability to use lansoprazole delayed release capsules contraindication per FDA label, intolerance, inability to use, or not a candidate for FOUR of the following: rabeprazole, omeprazole, pantoprazole, esomeprazole, or Dexilant candidate for FIVE of the following: rabeprazole, lansoprazole, omeprazole, pantoprazole, esomeprazole, or Dexilant Page 23 of 33

24 Gastrointestinal Agents: 5-HT3 receptor antagonists Lotronex (alosetron 0.5 mg and 1 mg Growth Hormone Genotropin Nutropin Norditropin Omnitrope Saizen Zomacton Hormones: oral corticosteroids Dexpak (dexamethasone 1.5 mg ZonaCort 7 Day and 11 Day (dexamethasone 1.5 mg ZoDex 6-Day and 12-Day Tablet (dexamethasone 1.5 mg) Rayos (prednisone 1 mg, 2 mg, and 5 mg delayed release Infertility Bravelle Gonal-F Lotronex contraindication per FDA lable, intolerance or not a candidate for FOUR of the following: clidinium/ chlordiazepoxide, dicyclomine, hyoscyamine, rifaximin, Viberzi Follow Somatropin Coverage Policy #4012 for additional criteria Growth Hormone Coverage Policy Documented inability to use dexamethasone 1.5 mg tablets candidate for methylprednisolone tablet therapy pack contraindication per FDA label, or intolerance to hydrocortisone and methylprednisolone tablets Documented intolerance or inability to use prednisone 1 mg, 2.5 mg, and 5 mg tablets contraindication per FDA label, or intolerance to dexamethasone, hydrocortisone, and methylprednisolone tablets Follow Infertility Injectables Coverage Policy #1012 for additional criteria Opioid Reversal Agents Sedative Hypnotics Evzio (naloxone 0.4 mg / 0.4 ml, 2 mg / 0.4 ml solution) Ambien (zolpidem 5 mg and 10 mg Ambien CR (zolpidem 6.25 mg and 12.5 mg Infertility Coverage Policy Member is currently using an opioid and is unable to use or obtain Narcan Nasal Spray (naloxone hydrochloride intranasal). Where covered, a maximum of two autoinjectors will be allowed per 30 days. Note: naloxone HCL for injection is also available Ambien candidate for eszopiclone and zaleplon Ambien CR Page 24 of 33

25 Psychotherapeutic Drugs:ADD/ADHD and Stimulants extended release Edluar (zolpidem 5 mg and 10 mg sublingual Intermezzo (zolpidem 1.75 mg and 3.5 mg sublingual Cotempla XR ODT (methylphenidate extended-release orally disintegrating tablets 8.6 mg, 17.3 mg and 25.9 mg) Desoxyn (methamphetamine 5 mg Dexedrine (dextroamphetamin e 5 mg, 10 mg, 15 mg sustained release capsules) candidate for eszopiclone, zaleplon, and zolpidem Documented inability to use zolpidem 5 mg or 10 mg tablets contraindication per FDA label, intolerance, or inability to use TWO of the following: eszopiclone, zaleplon, Silenor Intermezzo contraindication per FDA label, intolerance, inability to use, or not a candidate for TWO of the following: eszopiclone, zaleplon, Silenor Documented diagnosis of insomnia when a middle-of-thenight awakening is followed by difficulty returning to sleep when at least 4 hours of bedtime remain before the planned time of waking Treatment of Attention Deficit Hyperactivity Disorder (ADHD) in a pediatric individual 6 to 17 years of age Documented contraindication per FDA label, intolerance, inability to use, or not a candidate (e.g., stabilized condition where therapeutic interchange is inappropriate) for FIVE of the following: o Methylphenidate ER tablet (generic for Ritalin SR) or Metadate ER tablet (methylphenidate ER) o Methylphenidate ER tablet (generic for Concerta) o Methylphenidate ER capsules (generic for Ritalin LA) o Dexmethylphenidate XR (generic for Focalin XR) o Aptensio XR (methylphenidate ER capsules) o Quillichew ER (methylphenidate ER chewable o Quillivant XR (methylphenidate ER suspension) o Daytrana (methylphenidate transdermal patch) Desoxyn candidate for (e.g., stabilized condition where therapeutic interchange is inappropriate) ALL of the following: o dextroamphetamine/amphetamine (generic for Adderall) o dextroamphetamine (Procentra solution or generic for Zenzedi) Dexedrine candidate for (e.g., stabilized condition where therapeutic interchange is inappropriate) ALL of the following: Page 25 of 33

26 o dextroamphetamine/amphetamine ER (generic for Adderall XR), Vyvanse ((lisdexamfetamine dimesylate) Psychotherapeutic Drugs: Analeptics Psychotherapeutic Drugs: Benzodiazepines Psychotherapeutic Drugs: Miscellaneous Mydayis (mixed salts of a singleentity amphetamine product 12.5 mg, 25 mg, 37.5 mg, 50 extended-release capsules) Nuvigil (armodafinil 50 mg, 150 mg, 200 mg, and 250 mg Provigil (modafinil 100 mg and 200 mg Ativan (lorazepam) Restoril (temazepam 7.5 mg, 15 mg. 22.5mg, 30mg capsules) Horizant (gabapentin enacarbil 300 mg and 600 mg extended release Treatment of Attention Deficit Hyperactivity Disorder (ADHD) in an individual 13 years of age and older Failure or inadequate response, contraindication per FDA label, intolerance, inability to use, or not a candidate (e.g., stabilized condition where therapeutic interchange is inappropriate) for ALL of the following: o Dextroamphetamine/amphetamine ER capsule (generic for Adderall XR) o Dextroamphetamine ER (generic for Dexadrine) o Adzenys XR-ODT (amphetamine ER orally disintegrating tablet) o Dyanavel XR (amphetamine ER suspension) o Vyvanse (lisdexamfetamine capsule or chewable tablet) Follow Modafinil/ Armodafinil Coverage Policy #1501 for additional criteria Modafinil/ Armodafinil Coverage Policy Ativan candidate for TWO of the following: alprazolam, clonazepam, diazepam, oxazepam, temazepam Documented in tolerance to 1 generic formulation of Restoril candidate for TWO of the following: estazolam, eszopiclone, flurazepam, quazepam,triazolam, zaleplon, zolpidem, Doral, Silenor or Rozerem One of the following: Documented diagnosis of restless legs syndrome and ALL of the following: o Documented failure / inadequate response to gabapentin 300 mg capsules or gabapentin 600 mg o tablets Documented failure / inadequate response, candidate for ALL of the following: Lyrica, ropinirole immediate release tablets, pramipexole immediate release tablets, and levodopa / carbidopa tablets Documented diagnosis of postherpetic neuralgia and ALL of the following: Page 26 of 33